Is Swedish Snuff Tobacco A Viable Alternative For Smokers Prior To Surgery?

Big Tobacco will have to change to survive. My prediction is tobacco will actually become much safer in the coming years. In the future, there may be health benefits (via vitamins or mineral adjuncts) that manufacturers will try to implement into the tobacco delivery system all the while limiting the harmful effects of the drug. The industry only wants revenue and repeat customers, not health problems.

It is well known that smoking cigarettes causes multiple medical problems. I have personally encountered peripheral vascular disease, delayed wound healing, infection, delayed union or nonunion, and avascular necrosis in my patients who smoke. There is no arguing the many harmful effects of smoking tobacco, especially in the context of surgical healing.

We have seen that fractures have an increased risk of failure to heal in cigarette smokers.¹ Cessation of smoking during the first six weeks after open reduction internal fixation decreases the risk of postoperative complications.² The longer patients stop smoking prior to surgery, the fewer postoperative complications they will experience across a wide array of surgical interventions.³ There are articles in which the authors recommended smoking cessation prior to foot surgery.^4,5 It is important to remember that smoking is a modifiable risk factor and the majority of patients — as high as 80 percent — will quit or cut back with counseling prior to surgery.⁶

Are all tobacco products equal? As tobacco options evolve and new products are available, the literature is starting to show some tobacco products are safer than others. Most of the literature evaluates the cancer and heart disease risk in its relationship to standard “international” oral snuff.

My suspicion over the years has been that Swedish oral snuff is safer than other forms of tobacco. Snuff is a “designer” tobacco product that is gaining popularity here in the states. It has been popularized in Sweden for years, where over 20 percent of the male population and 3 percent of the female population regularly use snuff. Different than traditional American snuff tobacco, the Swedish snuff has been pasteurized, it is not allowed to ferment and has markedly fewer carcinogenic nitrosamines. Nicotine is present but nicotine may not be the component of these products that ultimately increases the health risks. It is debatable if the health risks of tobacco are due to nicotine or the other components of tobacco.⁷

Recent research has demonstrated that the use of snuff may not compromise healing in foot and ankle surgery. One study focused on 175 male patients (41 smokers, 21 oral snuff users and 113 non-tobacco users) who had surgery for tibial deformities with callus distraction and external fixation techniques.⁸ Oral snuff users had the shortest time in external fixation at 87 days in comparison to smokers at 100 days and non-tobacco users at 93 days. The risk of smokers developing complications versus snuffers was a 6:1 risk ratio. Surgeons removed external fixation when radiographs, ultrasound and reduced clinical pain showed stability. The authors concluded that oral snuff does not delay bone healing or increase the risk of postoperative complications whereas cigarette smoking does contribute to these complications. Although the results of this study are promising, the sample size is small and the findings should have further study and confirmation with additional research.

I do not promote tobacco use. In my practice, I view smoking tobacco as a relative contraindication to most elective surgery. I also alter my postoperative protocols, hardware and biologics for those who smoke cigarettes. However, I have not seen the same complications and thus do not alter my protocols in those patients who use other forms of tobacco, in particular Swedish snuff. I would rather have my patients quit smoking prior to surgery than continue to use tobacco products. However, this substance may be a reasonable alternative for patients who cannot quit smoking prior to surgery as a way to minimize complications with the healing process postoperatively.

References

1. Sarraf KM, Tavare A, Somashekar N, Langstaff RJ. Non-union of an undisplaced radial styloid fracture in a heavy smoker: revisiting the association of smoking and bone healing. Hand Surg. 2011; 16(1):73–76.

2. Nasell H, Adami J, Samnegard E, Tonnesen H, Ponzer S. Effect of smoking cessation intervention on results of acute fracture surgery: a randomized controlled trial. J Bone Joint Surg Am. 2010; 92(6):1335-42.

3. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011; 124(2):144–154.

4. Sherwin MA, Gastwirth CM. Detrimental effects of cigarette smoking on lower extremity wound healing. J Foot Surg. 1990; 29(1):84–87.

5. Haverstock BD, Mandracchia VJ. Cigarette smoking and bone healing: implications in foot and ankle surgery. J Foot Ankle Surg. 1998; 37(1):69–74.

6. Walker NM, Morris SA, Cannon LB. The effect of pre-operative counseling on smoking patterns in patients undergoing forefoot surgery. Foot Ankle Surg. 2009; 15(2):86–89.

7. Gullihorn L, Karpman R Lippiello L. Differential effects of nicotine and smoke condensate on bone cell metabolic activity. J Orthop Trauma. 2005; 19(1):17-22.

8. Dale AW, Larson ST. No delayed bone healing in Swedish Male oral snuffers operated on by the hemicallotasis technique. A cohort study of 175 patients. Act Orthopaedica. 2007; 78(6):791-94.